Clinical Applications

Anabolic/androgenic steroids are approved for sale by prescription in virtually every pharmaceutical market around the world. Having been applied for many decades to treat a variety of diseased states, today these drugs have a number of well-established medical uses. They have been used to treat most patient populations, including men and women of almost all ages, ranging from children to the elderly. In many instances anabolic/androgenic steroids have proven to be life saving medications, which is a fact easily overlooked with all of the discussion about steroid abuse. This section details some of the most common and accepted medical applications for anabolic/androgenic steroids.

Androgen Replacement TherapyIHypogonadism

The most widely used medical application for anabolic/androgenic steroids in the world is that of androgen replacement therapy. Also referred to as Hormone Replacement Therapy (HRT) or Testosterone Replacement Therapy (TRT), this therapy involves the supplementation of the primary male hormone testosterone to alleviate symptoms of low hormone levels (clinically referred to as hypogonadism). Patients may be adolescent males suffering from childhood hypogonadism or a specific disorder that causes androgenic hormone disruption, although most of the treated population consists of adult men over the age of

30. In most cases hormone levels have declined in these men as a result of the normal aging process.

The most common complaints associated with low testosterone in adult men include reduced libido, erectile dysfunction, loss of energy, decreased strength and/or endurance, reduced ability to play sports, mood fluctuations, reduced height (bone loss), reduced work performance, memory loss, and muscle IOSS.50 When associated with aging, these symptoms are collectively placed under the label of"andropause': In a clinical setting this disorder is referred to as late-onset hypogonadism. Blood testosterone levels below 350ng/dL are usually regarded as clinically significant, although some physicians will use a level as low as 200ng/dL as the threshold for normal. Hypogonadism is, unfortunately, still widely under-diagnosed. Most physicians will also not recommend treatment for low testosterone unless a patient is complaining about symptoms (symptomatic androgen deficiency).

Androgen replacement therapy effectively alleviates most symptoms of low testosterone levels. To begin with, raising testosterone levels above 350ng/dL (the very low end of the normal range) will often restore normal sexual function and libido in men with dysfunctions related to hormone insufficiency. With regard to bone mineral density, hormone replacement therapy is also documented to have a significant positive effect. For example, studies administering 250 mg of testosterone enanthate every 21 days showed a 50/0 increase in bone mineral density after six months.51 Over time this may prevent some loss of height and bone strength with aging, and may also reduce the risk of fracture. Hormone replacement therapy also increases red blood cell concentrations (oxygen carrying capacity), improving energyand senseofwell-being.Therapyalso supportsthe retention of lean body mass, and improves muscle strength and endurance.

Unlike steroid abuse, hormone replacement therapy in older men may also have benefits with regard to cardiovascular disease risk. For example, studies tend to show hormone replacement as having a positive effect on serum lipids. This includes a reduction in LDL and total cholesterol levels, combined with no significant change in HDL (good) cholesterol levels.52 53 Testosterone supplementation also reduces midsection obesity, and improves insulin sensitivity and glycemic control.54 These are important factors in metabolic syndrome, which may also be involved in the progression of atherosclerosis. Additionally, testosterone replacement therapy has been shown to improve the profile of inflammatory markers TNF·, IL-1" and IL-10.55 The reduced inflammation may help protect arterial walls from degeneration by plaque and scar tissue. The medical consensus today appears to be that replacement therapy generally does not have a negative effect on cardiovascular disease risk, and may actually decrease certain risk factors for the disease in some patients.

In addition to the normal list of potential side effects, there are a few areas of caution with elderly patients. To

begin with, testosterone administration may increase prostate volume and PSA values.56 57 While this does not appear to be of clinical significance with normal healthy patients, benign prostate hypertrophy and prostate cancer can be stimulated by testosterone. Men with prostate cancer, high PSA values, or breast cancer are generally not prescribed testosterone. Androgen supplementation, has also been linked to sleep apnea, which can interfere with the most restful (REM) phase of sleep.58 The studies have produced conflicting data, however, and the potential relationship remains the subject of much debate.59 Lastly, testosterone replacement therapy has demonstrated negative, positive, and neutral effects on cognitive functioning in elderly men.60 61 62 Studies do suggest that the dose can dictate the level of response, with the most positive effects noted when the androgen level reaches the midto upper-range of normal, not supraphysiological.63 Elderly patients with preexisting deficits in cognitive function should have their cognitive performance and blood hormone levels monitored closely during hormone replacement therapy.

Common Treatment Protocols:

Transdermal: Transdermal application is the most commonly prescribed method for supplementing testosterone in the United States and Canada, and is generally the first course of therapy initiated with androgen replacement therapy patients. This method of drug delivery offers a number of advantages to the patient when compared to injection. Since the transdermal application is painless, patient compliance and comfort is increased in comparison. Transdermal application also provides stable day-to-day hormone levels, and does not produce the broad fluctuations usually noticed with injectable testosterone esters. The most common protocol among hormone replacement doctors is to prescribe a dosage of 2.5-10 mg of testosterone per day (approximate absorbed dose).This is applied as a rub-on gel or adhesive transdermal patch that is replaced daily. Note that due to metabolism in the skin, transdermal application of testosterone tends to increase serum dihydrotestosterone (DHT) levels more profoundly than testosterone injection. This may exacerbate androgenic side effects during therapy in some patients, causing some to seek out injectable forms of testosterone as an alternative.