Hospital morbidity due to anabolic-androgenic steroids (AAS) consumption in Brazil

Silva Junior, Sérgio Henrique Almeida da

doi:10.1590/S1517-86922013000200007

Abstracts

INTRODUCTION: Anabolic androgenic steroids (AAS) are male sex hormones, developers and maintainers of sexual characteristics associated with masculinity and the anabolic status of somatic tissues. The physical and mental effects of AAS abuse are rare and it is almost impossible to say with certainty what adverse effects may become evident after their self-administration; however, they constitute risk of death for the individuals. OBJECTIVE: The aim of this study was to describe the main characteristics of morbidity by AAS ingestion in Brazil in the 2000/2010 period. METHODS: Information on hospitalizations was obtained from computerized databases of the Ministry of Health. In the analysis of AAS consumption as primary or secondary diagnosis for hospital admission, the E28.1 (androgen excess), E34.5 (androgen insensitivity syndrome), T38.7 (adverse effect of and underdosing of androgens and anabolic congeners) and Y42.7 (adverse effects in the therapeutic use of androgens and anabolic congeners) codes of the ICD-10 were used. RESULTS: Hospitalizations by AAS were responsible for 0.001% of total admissions in the country. 1,319 admissions (mean = 119.9, SD = 99.01) were accounted. The Androgen insensitivity syndrome was the primary cause, corresponding to 55.8% of total admissions. Of of all hospitalizations, 1% of patients died and the maximum stay was of 47 days (mean = 3.8, SD = 4.7). Minas Gerais, Maranhão and Espírito Santo presented the highest rates of hospital admissions per 1,000,000 inhabitants from 2002 to 2007. Women and people aged 15-29 presented the highest hospitalization rate 82.5% and 37.7%, respectively. CONCLUSION: The results of this study showed that the hospitalization rate was relatively low for AAS intake; women and individuals aged 15-29 years possessed the highest rates in the period studied.

anabolic agents; adverse effects; hospitalization

INTRODUÇÃO: Os esteroides anabólico-androgênicos (EAA) são hormônios sexuais masculinos, promotores e mantenedores das características sexuais associadas à masculinidade e do status anabólico dos tecidos somáticos. Os efeitos físicos e mentais do uso abusivo de EAA são raros e é praticamente impossível afirmar com certeza quais os efeitos adversos que poderão tornar-se evidentes após a autoadministração, mas os mesmos constituem risco de morte para os indivíduos. OBJETIVO: O objetivo do presente estudo foi descrever as principais características da morbidade por ingestão de EAA no Brasil, no período de 2000/2010. MÉTODOS: As informações sobre as internações hospitalares foram obtidas dos bancos de dados informatizados do Ministério da Saúde. Na análise da ingestão de EAA como diagnóstico principal e secundário de hospitalização, partiu-se das causas de internação sob os códigos E28.1 (excesso de andrógenos), E34.5 (síndrome de resistência a andrógenos), T38.7 (intoxicação por andrógenos e anabolizantes congêneres) e Y42.7 (efeitos adversos de andrógenos e anabolizantes congêneres) do CID-10. RESULTADOS: As hospitalizações por EAA foram responsáveis por 0,001% do total de internações do País. Foram contabilizadas 1.319 internações (média = 119,9, DP = 99,01). A síndrome de resistência a andrógenos foi a principal causa, correspondendo a 55,8% do total de internações. Do total de internações, 1% dos pacientes evoluiu para óbito e o tempo máximo de permanência foi de 47 dias (média = 3,8 e DP = 4,7). Minas Gerais, Maranhão e Espírito Santo possuíram as maiores taxas de internações por 1.000.000 de habitantes, nos anos de 2002 a 2007. As mulheres e a faixa etária de 15-29 tiveram maiores taxas, 82,5% e 37,7%, respectivamente. CONCLUSÃO: Os resultados do presente estudo mostraram uma hospitalização por ingestão de EAA relativamente baixa, as mulheres e indivíduos na faixa etária de 15-29 anos possuíram as maiores taxas no período estudado.

anabolizantes; efeitos adversos; hospitalização

ORIGINAL ARTICLE

EXERCISE AND SPORTS MEDICINE CLINIC

Hospital morbidity due to anabolic-androgenic steroids (AAS) consumption in Brazil

Sérgio Henrique Almeida da Silva Junior

Sérgio Arouca National School of Public Health ENSP/FIOCRUZ

Mailing address

ABSTRACT

INTRODUCTION: The anabolic-androgenic steroids (AAS) are male sex hormones, developers and maintainers of sexual characteristics associated with masculinity and the anabolic status of somatic tissues. The physical and mental effects of AAS abuse are rare and it is practically impossible to say with certainty what adverse effects may become evident after self-administration, but they constitute risk of death for individuals.

OBJECTIVE: The aim of this study was to describe the main characteristics of morbidity due to AAS intake in Brazil, in the period 2000/2010.

METHODS: Information on hospitalizations was obtained from computerized databases of the Ministry of Health. In the analysis of the consumption of AAS as primary or secondary diagnosis, the codes E28.1 (androgen excess), E34.5 (androgen insensitivity syndrome), T38.7 (adverse effect of and underdosing of androgens and anabolic congeners) and Y42.7 (adverse effects in the therapeutic use of androgens and anabolic congeners) of the ICD-10 were used.

RESULTS: Hospitalizations due to AAS were responsible for 0.001% of total admissions in the country. 1,319 admissions (mean = 119.9, SD = 99.01) were counted. The Androgen insensitivity syndrome was the primary cause, corresponding to 55.8% of total admissions. Out of all hospitalizations, 1% of patients died and the longest stay was of 47 days (mean = 3.8, SD = 4.7). Minas Gerais, Maranhão and Espírito Santo present the highest rates of hospital admissions per 1,000,000 inhabitants between the years 2002 and 2007. Women and individuals aged 15-29 presented higher hospitalization rate, 82.5% and 37.7%, respectively.

CONCLUSION: The results of this study showed that the rate of hospitalization was relatively low for AAS intake. Women and individuals aged 15-29 years presented the highest rates in the period studied.

Keywords: anabolic agents, adverse effects, hospitalization.

INTRODUCTION

The anabolic steroids or anabolic-androgenic steroids (AAS) are male sexual hormones, promoters and maintainers of the sexual characteristics associated with masculinity and anabolic status of the somatic tissues¹. They include testosterone and its by-products, which are "building" substances of the muscle tissue.

The use of these substances with ergogenic purpose started in 1889, when the investigator Brown-Séquard² self-injected an extract which contained a mixture made from dogs' and laboratory animals' testicles; he imagined that he would increase his vitality. In 1930, testosterone was finally isolated and characterized in Germany^3,4. In the following years, countless testosterone by-products were synthetized and the so-called AAS hormones were created⁵.

Right after the introduction of AAS as possible therapeutic agents, the athletes found out that these drugs would be able to enable higher levels of muscular mass, beyond the ones naturally obtained⁶. These substances rapidly spread within the elite athletic community, and, in 1954, the Russian team was caught in the weightlifting championship in Vienna⁷.

The physical and mental effects of abusive use of anabolic steroids are rare and it is almost impossible to state for sure which adverse effects will be able to become evident after self-administration of massive dosing of many combinations of different AAS for a long period, but these constitute a risk of death for individuals⁸.

The majority of the information available about the adverse effects of these substances is published as case studies. Thiblin and Petersson, state that the AAS may be lethal or bring physical complications, such as heart diseases, cardiomyopathy, pulmonary embolism or stroke⁹. Recent studies using modern image techniques found out association between the use of AAS and diastolic dysfunction and subclinical left ventricular dysfunction^10-12.

Further evidence indicates that AAS may cause psychiatric complications aassociated with higher risk of premature death. In the study by Pope and Katz, 23% of the AAS users reported mood swings and depression; Teuber et al found acute paranoid psychosis problems; Perry and Hughes, affective disorder and schizophrenia episodes^13-15.

AAS deeply affects the endocrine and reproductive systems. Alén et al. and Yesalis reported that these substances induced low fertility in men and its prolonged use may produce transitory testicular insufficiency^16-18.

Besides the effects presented here, clinical studies have demonstrated association between the use of AAS and the use of opiates and/or other psychoactive substances, such as marijuana, cocaine, amphetamines or LSD (lysergic acid diethylamide)^19-23.

The Hospital Admission Authorization (AIH) is a mandatory instrument filled out in hospitals for patients' hospitalization paid by the unified public health system. This document contains all the information about the hospitalizations, such as demographic data, diagnostic, procedures carried out and costs, which makes the profile of the morbidity helped by this part of the system available, and very importantly, the calculation of the costs of the different causes for the hospitalization.²⁴

The AIH system is currently responsible for 80% of the medical-hospital assistance offered to the Brazilian population and represents about 1,000,000 of monthly hospitalizations (approximately 12,000,000 of hospitalizations/year) in 6,380 hospital units.

The aim of the present study is to describe the main characteristics of morbidity due to anabolic-androgenic steroids intake in Brazil between 2000 and 2010, through analyses of the AIH.

METHODS

The data from the hospitalizations due to anabolic-androgenic steroids intake in Brazil between 2000 and 2010 were obtained from digital databases from the Ministry of Health, which contains data from all the hospitalizations occurred through the Hospital Admission Authorization (AIH) of the Unified Health System (SUS)

In the analysis of the anabolic steriods intake as main and secondary diagnosis for hospitalizations, the starting point were the causes for submission under the E28.1 (androgen excess); E34.5 (androgen resistance syndrome); T38.7 (intoxication by androgens and anabolic congeners) and Y42.7 (adverse effects of androgens and anabolic congeners) codes of the International Statistical Classification of Diseases and Health-Related Problems 10th revision (CID-10)²⁵.

The hospitalization rates were calculated as the number of submissions in an area in a given year divided by its resident population in the same year and multiplied by 1,000,000. The population data for the years in study were obtained from the Brazilian Institute of Geography and Statistics (IBGE)

RESULTS

Hospitalizations due to AAS in Brazil in the last 11 years were responsible for about 0.001% of the total of hospitalizations in the country. In that period, 1,319 submissions were counted (mean = 119.9, SD = 99.01), where the year of 2002 presented the highest number (table 1).

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The androgen resistance syndrome was the main cause, corresponding to 55.8% of the total of submissions in the studied period. Intoxication by androgen and anabolic congeners and androgen excess participated with 41.35% and 2.6% out of the total, respectively.

Among the submitted patients, 1% developed to death, the longest hospitatization period was of 47 days (mean = 3.8 and SD = 4.7). Age mean was 27.7 years (SD = 19.5 years).

Generally speaking, Minas Gerais, Maranhão and Espírito Santo presented the highest hospitalization rates per 1,000,000 inhabitants from 2002 to 2007. The state of Tocantins in 2002 reached the rate of 8.3 per 1,000,000 in habitants (table 2).

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Figure 1 presents the tendency along the passage of time and the number of the hospital morbidity due to anabolic-androgenic steroids intake. The cases concentrated in the period between 2002 and 2007, presenting light decrease in the year of 2006.

Women and the age range of 15-29 presented the highest hospitalization rate, 82.5% and 37.7%, respectively (table 3). The as circumstances concerning lifestyle were the main cause associated with morbidity by androgen intake (11.9%). Decrease of (3.3%) and vagina narrowing and atresia^1,4, were also important causes.

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DISCUSSION

The motivation to the AAS use presents most of the times an esthetic nature. According to Freitas²⁶, we are worried about "losing the belly", "enlarging the biceps", "diminishing the nose", as if the parts of our bodies were disconnected from us and if the suffered alterations by one of them were not in fact alterations of the whole, and, therefore, with implications as a whole as well.

The scientific literature has associated for a long time these substances with a series of negative consequences to the users; however, it is difficult to accurately predict the collateral effects promoted by its clinical use and besides of that, the nature of the association between AAS and the hospital discharge or deaths which need to be better explained, since there are few data about the effect of these substances during one's life.

The hospitalization rate due to AAS intake in Brazil was relatively low, a fact which can be explained by the cases under-recording, since there is no filling out of the AIH form in the immediate care units and this aggravation is not necessarily notified.

Another important factor to be investigated is the quality of the submissions' diagnosis, since, according to Pinheiro²⁷, standard and reliable information is essential to the quality monitoring and health services coverage.

Under-notification, under-recording, missing information in some spaces in the form as well as system's coverage are elements which compromise the estimations of clinical-epidemiological parameters, causing many times misinterpretation from the part of health providers and professionals about the relevance and magnitude of diseases.

The circumstances concerning lifestyle, falls and vaginal narrowing and atresia were the diagnosis mostly associated with AAS intake. Petersson et al.²⁸, in a cohort study with 1,463 Swedish indviduals, found out that AAS users present 2.2 more risk of hospital admission for abusive consumption (CI95% = 1.2-4.2), 2.1 risk for psychiatric disorders (CI95% = 1.4-3.2) and 3.5 for thoracic pain (CI95% = 1.1-10.9). The standard mortality reasons (SMR) in this study in positive and negative patients were 20.43 (CI95% = 10.56-35.70) and 6.02 (CI 95% = 3.77-9.12), respectively.

Pärssinen et al.²⁹, found risk of death of 4.6 (CI95% = 2.04-1.45) in Finnish individuals with suspicion of AAS consumption. The cases of premature death were associated with suicide, acute myocardial infarction, hepatic coma and Hodgkin's lymphoma.

CONCLUSION

The results of the present study presented relatively low hospitalization rate due to AAS consumption; women and individuals aged 15-29 years presented the highest rates in the studied period.

REFERENCES

1. Degroot L& Jameson JL. Endocrinolog:. 5^o ed. Saunder , 2005.
2. Brown-Séquard C. Des effets produits chez l'homme par des injections souscutanées d'un liquide retiré des testicules frais de cobaye et de chien. C R Séance Soc Biol 1889.
3. David K, Dingemanse E, Freud J, Laqueur E. Über krystallinisches männliches Hormon aus Hoden (Testosteron), wirksamer als aus Harn oder aus Cholesterin bereitetes Androsteron. Hoppe-Seyler´s Zeitschrift für Physiologische Chemie 1935;233:281-3.
4. Wettstein A. Uber die kunstliche Herstellung des Testikelhormons Testosteron. Schweiz Med. Wochenschr. 1935.
5. Kopera H. The history of anabolic steroids and a review of clinical experience with anabolic steroids. Acta Endocrinol Suppl (Copenh) 1985;271:11-8.
6. Kanayama G, Hudson JI, Pope HG. Long-Term Psychiatric and Medical Consequences of Anabolic-Androgenic Steroid Abuse. Drug Alcohol Depend 2008;98(1-2):1-12.
7. Wade N. Anabolic Steroids: Doctors Denounce Them, but Athletes Aren't Listening. Science 1972;176:1399-403.
8. Lamb DR. O Uso abusivo de esteroides anabolizantes no Esporte. GSSI 1996.
9. Thiblin I, Petersson A. Pharmacoepidemiology of anabolic androgenic steroids: a review. Fundam Clin Pharmacol 2005;19:27-44.
10. D'Andrea A, Caso P, Salerno G, Scarafile R, De Corato G, Mita C, et al. Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: a Doppler myocardial and strain imaging analysis. Br J Sports Med 2007;41:149-55.
11. Krieg A, Scharhag J, Albers T, Kindermann W, Urhausen A. Cardiac tissue Doppler in steroid users. Int J Sports Med 2007;28:638-43.
12. Nottin S, Nguyen L-D, Terbah M, Obert P. Cardiovascular effects of androgenic anabolic steroids in male bodybuilders determined by tissue Doppler imaging. Am J Cardiol 2006;97:912-5.
13. Pope HG Jr, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use. A controlled study of 160 athletes. Arch Gen Psychiatry 1994;51:375-82.
14. Teuber I, Freiwald D, Volz H-P. [Acute paranoid psychotic symptoms after i.m. injection of nandrolone]. Psychiatr Prax 2003;30 Suppl 2:S73-4.
15. Perry HM, Hughes GW. A case of affective disorder associated with the misuse of "anabolic steroids". Br J Sports Med 1992;26:219-20.
16. Alén M, Reinilä M, Vihko R. Response of serum hormones to androgen administration in power athletes. Med Sci Sports Exerc 1985;17:354-9.
17. Yesalis C. Anabolic Steroids in Sport and Exercise. Human Kinetics, 2000.
18. Ruokonen A, Alén M, Bolton N, Vihko R. Response of serum testosterone and its precursor steroids, SHBG and CBG to anabolic steroid and testosterone self-administration in man. J Steroid Biochem 1985;23:33-8.
19. Kanayama G, Cohane GH, Weiss RD, Pope HG. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: an underrecognized problem? J Clin Psychiatry 2003;64:156-60.
20. Arvary D, Pope HG Jr. Anabolic-androgenic steroids as a gateway to opioid dependence. N Engl J Med 2000;342:1532.
21. Durant RH, Ashworth CS, Newman C, Rickert VI. Stability of the relationships between anabolic steroid use and multiple substance use among adolescents. J Adolesc Health 1994;15:111-6.
22. Wichstrøm L, Pedersen W. Use of anabolic-androgenic steroids in adolescence: winning, looking good or being bad? J Stud Alcohol 2001;62:5-13.
23. Kindlundh AM, Isacson DG, Berglund L, Nyberg F. Factors associated with adolescent use of doping agents: anabolic-androgenic steroids. Addiction 1999;94:543-53.
24. Levcovitz E, Pereira TRC. SIH/SUS (Sistema AIH): uma análise do sistema público de remuneração de internações hospitalares no Brasil-1983-1991; SIH/SUS (system AIH). Estudos em Saúde Coletiva 1993;57.
²⁵
Saúde O-OMD. CID-10, V.1 - Classificação Internacional de Doenças -Problemas relacionados a saúde. EdUSP; 2000.
26. Freitas GGD. Esquema corporal, a imagem corporal, a consciência corporal e a corporeidade. UNIJUI. 2004.
27. Pinheiro RS, Oliveira GP de, Oliveira PB, Coeli CM. Melhoria da qualidade do sistema de informação para a tuberculose: uma revisão da literatura sobre o uso do linkage entre bases de dados [Internet]. Disponível em: portal.saude.gov.br/portal/arquivos/.../cap_8_saude_brasil_2010.pdf
28. Petersson A, Garle M, Granath F, Thiblin I. Morbidity and mortality in patients testing positively for the presence of anabolic androgenic steroids in connection with receiving medical care. A controlled retrospective cohort study. Drug Alcohol Depend 2006;81:215-20.
29. Pärssinen M, Kujala U, Vartiainen E, Sarna S, Seppälä T. Increased premature mortality of competitive powerlifters suspected to have used anabolic agents. Int J Sports Med 2000;21:225-7.

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²

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Publication Dates

Publication in this collection
03 June 2013
Date of issue
Apr 2013

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Degroot L& Jameson JL. Endocrinolog:. 5^o ed. Saunder , 2005.

[2] 2. Brown-Séquard C. Des effets produits chez l'homme par des injections souscutanées d'un liquide retiré des testicules frais de cobaye et de chien. C R Séance Soc Biol 1889.

[3] 3. David K, Dingemanse E, Freud J, Laqueur E. Über krystallinisches männliches Hormon aus Hoden (Testosteron), wirksamer als aus Harn oder aus Cholesterin bereitetes Androsteron. Hoppe-Seyler´s Zeitschrift für Physiologische Chemie 1935;233:281-3.

[4] 4. Wettstein A. Uber die kunstliche Herstellung des Testikelhormons Testosteron. Schweiz Med. Wochenschr. 1935.

[5] 5. Kopera H. The history of anabolic steroids and a review of clinical experience with anabolic steroids. Acta Endocrinol Suppl (Copenh) 1985;271:11-8.

[6] 6. Kanayama G, Hudson JI, Pope HG. Long-Term Psychiatric and Medical Consequences of Anabolic-Androgenic Steroid Abuse. Drug Alcohol Depend 2008;98(1-2):1-12.

[7] 7. Wade N. Anabolic Steroids: Doctors Denounce Them, but Athletes Aren't Listening. Science 1972;176:1399-403.

[8] 8. Lamb DR. O Uso abusivo de esteroides anabolizantes no Esporte. GSSI 1996.

[9] 9. Thiblin I, Petersson A. Pharmacoepidemiology of anabolic androgenic steroids: a review. Fundam Clin Pharmacol 2005;19:27-44.

[10] 10. D'Andrea A, Caso P, Salerno G, Scarafile R, De Corato G, Mita C, et al. Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: a Doppler myocardial and strain imaging analysis. Br J Sports Med 2007;41:149-55.

[11] 11. Krieg A, Scharhag J, Albers T, Kindermann W, Urhausen A. Cardiac tissue Doppler in steroid users. Int J Sports Med 2007;28:638-43.

[12] 12. Nottin S, Nguyen L-D, Terbah M, Obert P. Cardiovascular effects of androgenic anabolic steroids in male bodybuilders determined by tissue Doppler imaging. Am J Cardiol 2006;97:912-5.

[13] 13. Pope HG Jr, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use. A controlled study of 160 athletes. Arch Gen Psychiatry 1994;51:375-82.

[14] 14. Teuber I, Freiwald D, Volz H-P. [Acute paranoid psychotic symptoms after i.m. injection of nandrolone]. Psychiatr Prax 2003;30 Suppl 2:S73-4.

[15] 15. Perry HM, Hughes GW. A case of affective disorder associated with the misuse of "anabolic steroids". Br J Sports Med 1992;26:219-20.

[16] 16. Alén M, Reinilä M, Vihko R. Response of serum hormones to androgen administration in power athletes. Med Sci Sports Exerc 1985;17:354-9.

[17] 17. Yesalis C. Anabolic Steroids in Sport and Exercise. Human Kinetics, 2000.

[18] 18. Ruokonen A, Alén M, Bolton N, Vihko R. Response of serum testosterone and its precursor steroids, SHBG and CBG to anabolic steroid and testosterone self-administration in man. J Steroid Biochem 1985;23:33-8.

[19] 19. Kanayama G, Cohane GH, Weiss RD, Pope HG. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: an underrecognized problem? J Clin Psychiatry 2003;64:156-60.

[20] 20. Arvary D, Pope HG Jr. Anabolic-androgenic steroids as a gateway to opioid dependence. N Engl J Med 2000;342:1532.

[21] 21. Durant RH, Ashworth CS, Newman C, Rickert VI. Stability of the relationships between anabolic steroid use and multiple substance use among adolescents. J Adolesc Health 1994;15:111-6.

[22] 22. Wichstrøm L, Pedersen W. Use of anabolic-androgenic steroids in adolescence: winning, looking good or being bad? J Stud Alcohol 2001;62:5-13.

[23] 23. Kindlundh AM, Isacson DG, Berglund L, Nyberg F. Factors associated with adolescent use of doping agents: anabolic-androgenic steroids. Addiction 1999;94:543-53.

[24] 24. Levcovitz E, Pereira TRC. SIH/SUS (Sistema AIH): uma análise do sistema público de remuneração de internações hospitalares no Brasil-1983-1991; SIH/SUS (system AIH). Estudos em Saúde Coletiva 1993;57.

[25] ²⁵
Saúde O-OMD. CID-10, V.1 - Classificação Internacional de Doenças -Problemas relacionados a saúde. EdUSP; 2000.

[26] 26. Freitas GGD. Esquema corporal, a imagem corporal, a consciência corporal e a corporeidade. UNIJUI. 2004.

[27] 27. Pinheiro RS, Oliveira GP de, Oliveira PB, Coeli CM. Melhoria da qualidade do sistema de informação para a tuberculose: uma revisão da literatura sobre o uso do linkage entre bases de dados [Internet]. Disponível em: portal.saude.gov.br/portal/arquivos/.../cap_8_saude_brasil_2010.pdf

[28] 28. Petersson A, Garle M, Granath F, Thiblin I. Morbidity and mortality in patients testing positively for the presence of anabolic androgenic steroids in connection with receiving medical care. A controlled retrospective cohort study. Drug Alcohol Depend 2006;81:215-20.

[29] 29. Pärssinen M, Kujala U, Vartiainen E, Sarna S, Seppälä T. Increased premature mortality of competitive powerlifters suspected to have used anabolic agents. Int J Sports Med 2000;21:225-7.