Assessment of Anabolic Androgenic Steroids Use Among Professional CrossFit® Athletes: Motives, Perception, and Safety.

BACKGROUND: Anabolic androgenic steroids (AAS) are traditionally used for the treatment/control of various diseases; however, they are being used for non-therapeutic and indiscriminate purposes to enhance sports performance and physical appearance. This study aimed to assess the prevalence and associated factors of AAS use among professional CrossFit® competitors. METHODS: We conducted an observational cross-sectional survey in which an anonymous questionnaire was applied to professional CrossFit® athletes. RESULTS: The prevalence of AAS usage was 33.3%. Most users were male (74.2%), aged between 30 and 39 years (51.6%), with completed higher education (83.9%), and had been training for more than 5 years (77.4%); the primary motivation for AAS use was performance enhancement (77.4%). Individuals who were older (p < 0.05) and more experienced in competitions (p < 0.01) are more likely to use AAS. Testosterone was the most employed AAS (71.0%); CrossFit® athletes typically used an average of 2 different AAS. The majority of users had notably sought advice from a physician (74.2%), and AAS were acquired from either drugstores (80.6%) or through illicit channels (29.0%). Moreover, 61.3% of AAS users reported experiencing adverse effects. CONCLUSIONS: Our results demonstrated a higher prevalence of AAS users among professional competitors in CrossFit® compared to the general population; older age and greater experience in official competitions were decisive factors for a greater inclination toward AAS use. A significant percentage of athletes seek drugs through illegal channels. Despite the majority of users experiencing adverse effects, athletes report satisfaction with use, believing that the benefits still outweigh the drawbacks.

A qualitative assessment of anabolic-androgenic steroid use among gym users in Jordan: motives, perception, and safety.

BACKGROUND: Over the years, the use of anabolic-androgenic steroids (AAS) has become widespread among athletes and bodybuilders. The prevalence of their use has been estimated at around 20 to 50% globally. Unfortunately, many athletes do not have the proper knowledge about the effects of these banned substances Thus, this study aims to qualitatively assess Jordanian gym users' AAS intentions, perceptions, and safety. METHODS: Twenty male Jordanian anabolic steroid users were interviewed using in-depth interviews as part of a qualitative study evaluating the motivations, perceptions, and safety of AAS among gym users. RESULTS: The findings of this study indicate that the desire to compete in bodybuilding contests was the primary motivation for participants to use AAS. The study participants mentioned using a combination of oral and injectable medications. Gym coaches and trainers were also identified as an essential source of information for AAS use. A very limited number of AAS users were getting their information from healthcare providers, and most of them have experienced some of these medications side effects but are still willing to continue the use of AAS to get what they need in terms of their physical appearance or for winning competitions. CONCLUSION: There is an urgent need for structured awareness campaigns targeting gyms and fitness clubs' members to increase their knowledge about the side effects and health risks associated with the use of AAS. In addition, sports governing bodies should have stricter measures to tackle this problem and discourage athletes from using such products.

Health service engagement, side effects and concerns among men with anabolic-androgenic steroid use: a cross-sectional Norwegian study.

BACKGROUND: Recreational use of anabolic-androgenic steroids (AAS) is a public health concern world-wide associated with a range of physical and psychological side effects. Still, people who use AAS tend to be reluctant to seek treatment. This study aims to explore use characteristics, treatment-seeking behaviour, side effects and associated health concerns among men with AAS use. METHODS: The study includes cross-sectional self-report data from 90 men with a current or previous use of AAS exceeding 12 months, where 41 (45.6%) had sought treatment at least once during their lifetime, and 49 (54.4%) had not. Health service engagement was examined with descriptive statistics on reasons for contacting health services, transparency about AAS use, satisfaction with health services and reasons for not seeking treatment. Furthermore, experienced side effects and health concerns were compared between the treatment seeking and the non-treatment seeking group, using two-sample t-tests and Chi2 or Fisher exact tests for numerical and categorical variables, respectively. RESULTS: All 90 AAS-using men reported side effects from AAS use. Treatment seekers were significantly younger, experienced more side effects including gynecomastia, excessive sweating, fatigue, depression and anxiety, and expressed more concern for testosterone deficiency. Preventive health check-up was the most common reason for seeking treatment (n = 22, 53.7%), and 38 men (93%) were transparent about AAS use during consultations with health professionals. The main reported reasons for not seeking healthcare services were that the experienced side effects were not considered to be of treatment demanding nature (n = 39, 79.6%) and the belief that healthcare providers had scarce knowledge about AAS use and its health impacts (n = 12, 24.5%). CONCLUSIONS: Reluctance to seek treatment among people who use AAS, despite having associated side effects and health concerns, may contribute to continued health risks. It is important to fill the knowledge gap on how to reach and treat this new patient group, and policy makers and treatment providers need to be educated on how to meet their treatment needs.

Psychiatric morbidity among men using anabolic steroids.

OBJECTIVE: The purpose of this study was to investigate the psychiatric morbidity among men with abuse of anabolic steroids. METHODS: The design is a retrospectively matched cohort study. Five hundred and fourty-five males, who tested positive for anabolic steroids in Danish fitness centers during the period January 3, 2006 to March 1, 2018, were matched with 5450 randomly chosen male controls. Data was cross-referenced with seven national registers pertaining to information about education, employment status, and psychiatric comorbidity. Main outcomes and measures were prescription of psychopharmacological treatment. RESULTS: The incidence of treatment with anxiolytics (HR: 2.34, 95% CI: 1.62-3.38) and antipsychotics (HR: 2.69, 95% CI: 1.99-3.63) displayed a remarkable increase in the years following doping sanction, compared to the control group. The prevalence of antidepressant use was already markedly elevated several years before doping sanction, but also displayed a higher incidence in the years following sanction (HR: 1.65, 95% CI: 1.28-2.13). The associations remained highly significant after controlling for socioeconomic factors. CONCLUSION: Anabolic steroids use is strongly associated with psychiatric morbidity.

Anabolic-androgenic steroids and the risk of imprisonment.

BACKGROUND: The use of Anabolic-Androgenic Steroids (AAS) has been associated with increased aggressiveness and violent behavior. We therefore investigated the proposed correlation between the use of AAS and criminality while controlling for important socio-economics covariates and for psychiatric comorbidity. METHODS: The primary endpoints were prison sentences, and time to first prison sentence. A retrospective matched cohort study design consisting of 545 males, who tested positive for AAS in Danish gyms during the period January 3, 2006 to January 31, 2017. They were matched with 5450 randomly chosen male controls. Data were cross-referenced with national register information on education, employment status, substance abuse and psychiatric comorbidity. In addition, 638 males sanctioned because they rejected to participate in the doping control and 6380 controls were used as a replication cohort. RESULTS: Already at baseline, 20.6% of the AAS users had a previous prison sentence whereas the rate was 3.7% in the control cohort (p < 0.0001). During the follow-up period the cumulative prevalence increased to 29.5% and 4.9%, respectively (unadjusted HR 9.15, 95% CI 6.33-13.20). The associations remained highly significant after controlling for socio-economic factors, drug abuse and psychiatric comorbidity. The results could be replicated in a similar cohort. CONCLUSION: Our study shows that AAS users have a 9-fold increased risk of being convicted of a crime compared to matched controls, randomly chosen from the general population. This association could not be explained by common socioeconomic factors or by psychiatric comorbidity.

Anabolic androgen use in the management of hereditary angioedema: Not so cheap after all.

BACKGROUND: Hereditary angioedema due to C1 inhibitor deficiency (HAE) is a rare, life-threatening disease that imposes a significant burden on affected patients. 17α-alkylated androgens (anabolic androgens) decrease attack frequency and severity but carry the risk of potentially serious dose-related adverse effects. Despite the emergence of targeted therapies for HAE, continued anabolic androgen use has been driven in part by their low cost. OBJECTIVE: To examine the hidden cost of anabolic androgen use related to the risk of developing non-HAE comorbidities. METHODS: Patients with HAE were identified in the Southern California Kaiser Permanente database using clinical and laboratory findings compatible with HAE. These patients were stratified into anabolic androgen exposed and nonexposed groups. Matched controls were selected from the Kaiser database who did not have HAE or anabolic androgen exposure. Using multivariate analysis, we determined the number of non-HAE comorbidities linked to anabolic androgen use. We next determined the association between dosing and increasing exposure to anabolic androgens and the likelihood of having various comorbidities. RESULTS: Patients with HAE exposed to anabolic androgens had a 28% increase (P = .04) in non-HAE comorbidities when compared with their matched (nonexposed) controls. With each gram per month increase in exposure, a 12% increase in non-HAE comorbidities is observed (P < .01). The most commonly occurring non-HAE comorbidities were psychiatric, muscle cramps, obesity, and hyperlipidemia. CONCLUSION: Our data suggest that long-term anabolic androgen use enhances the risk of developing comorbid health conditions, thus amplifying the cost of care. Our report provides additional support for the preferred use of newer, targeted therapies for the management of HAE.

Avaliação descritiva sobre o uso de esteroides anabolizantes e seu efeito sobre as variáveis bioquímicas e neuroendócrinas em indivíduos que praticam exercício resistido / Descriptive assessment on the use of anabolic steroids and their effect on the biochemical and neuroendocrine variables in practitioners of resisted exercise

O uso dos esteroides anabolizantes vem se tornando um problema de saúde pública ao longo dos últimos anos. No bojo do uso abusivo, muitos efeitos deletérios são observados, na sua totalidade por disfunções dos vários sistemas fisiológicos. Sendo assim, o objetivo do estudo foi o de avaliar o eixo hipófise-gonadal, a função hormonal, as transaminases hepáticas e o perfil de hemograma de 61 voluntários distribuídos em três grupos: 20 usuários de esteroides anabolizantes praticantes de exercício físico resistido, 21 praticantes de exercício resistido sem uso de esteroides anabolizantes e 20 sedentários. Foi observada elevação do nível de creatina quinase nos dois grupos de indivíduos que se exercitavam de maneira resistida, em relação ao grupo de sedentários (p < 0,001). Redução das gonadotrofinas LH e FSH do grupo de usuários de esteroides anabolizantes e elevação do nível de estradiol, em comparação ao grupo sedentário e treinado que não usa esteroides anabolizantes (p < 0,001). Ainda, foi observada redução da fração HDL do colesterol, em relação aos dois grupos estudados (p < 0,001). Desta maneira, o uso dos esteroides anabolizantes causa alterações bioquímicas que podem levar a instalação de efeitos colaterais.

The use of anabolic asteroids has become a public health problem over the last years. Concerning their abusive use, many deleterious effects caused in their totality by dysfunction of the various physiological systems can be observed. Therefore, the aim of the present study was to assess the hypophyseal-gonadal axis, hormone function, hepatic transaminases and hemogram profile of 61 volunteers distributed in three groups: 20 anabolic steroid users, practitioners of resisted physical exercise; 21 practitioners of resisted physical exercise with no use of anabolic steroids and 20 sedentary subjects. Increase of the creatine kinase level was observed in the two exercised groups in comparison to the sedentary group (p < 0.001). Reduction of the LH and FSH gonadotrpins of the steroid users group and increase in the estradiol level were observed in comparison to the sedentary and with no steroid use groups (p < 0.001). Moreover, reduction of the HDL cholesterol fraction was observed in comparison to the two studied groups (p < 0.001). Thus, the use of anabolic steroids causes biochemical alterations which can lead to the installation of collateral effects.

Doping and effects of anabolic androgenic steroids on the heart: histological, ultrastructural, and echocardiographic assessment in strength athletes.

Anabolic androgenic steroids (AAS) are used by some athletes to enhance performance despite the health risk they may pose in some persons. This work was carried out to evaluate the possible structural and functional alterations in the heart using two-dimensional, M-mode, tissue Doppler imaging (TDI) and strain rate imaging (SRI) in athletes using supraphysiological doses of AAS. Additionally, the histological and ultrastructural changes in cardiac muscles of adult albino rats after injection of sustanon, as an example of AAS, were studied. Fifteen male bodybuilders using anabolic steroids constituted group 1, five male bodybuilders who are not using anabolic steroids constituted group 2, and five nonathletic males constituted negative control group (group 3). They were investigated by two-dimensional, M-mode, TDI and SRI. This study was performed on 30 adult albino rats. They were divided into two groups. Group I (Control group) (10) was subdivided into negative control, subgroup 1a (5), and subgroup 1b (5), which received 0.8 ml olive oil intramuscular once a week for 8 weeks. Group II (Experimental group) (20) received sustanon 10 mg/kg intramuscularly once a week for 8 weeks. The heart specimens were prepared for light microscopy and transmission electron microscopy. Echocardiographic results showed that bodybuilders who use steroids have smaller left ventricular dimension with thicker walls, impaired diastolic function, as well as higher peak systolic strain rate in steroid-using bodybuilders as compared to the other two groups. Light microscopy examination of cardiac muscle fibers showed focal areas of degeneration with loss of striations and vacuolation in the experimental group. Ultrastructural examination showed disturbance of the banding pattern of the cardiac muscle fiber with disintegration, loss of striations, dehiscent intercalated disc, and interrupted Z-bands. Administration of supraphysiological doses of AAS caused severe deleterious effects in the myocardium both in athletes and in experimental animals. The SRI shows promise in the early detection of systolic dysfunction in those athletes who use steroids.

Trauma, systemic inflammatory response syndrome, dietary supplements, illicit steroid use and a questionable malignant hyperthermia reaction.

BACKGROUND: Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle calcium regulation associated primarily, but not exclusively, with mutations in the skeletal muscle ryanodine receptor. Associated environmental factors, however, may also be important for expression of the syndrome. METHODS AND RESULTS: A 24-yr-old trauma patient developed a fulminant MH crisis after a 3 minute exposure to sevoflurane. A thorough evaluation of underlying co-morbidities revealed a number of environmental factors that could have altered skeletal muscle calcium regulation, and may have potentially influenced the effects of volatile inhaled anesthetics. Since MH is a syndrome characterized by abnormal skeletal muscle calcium regulation, other factors that alter calcium homeostasis may exacerbate the impact of inhaled MH-triggering drugs. CONCLUSIONS: While a thorough history of MH episodes in a proband and family is emphasized as part of a complete preanesthetic evaluation, obtaining a history of other environmental entities that may alter calcium regulation may be equally important to knowing the family history.

Growth hormone and anabolic steroids: athletes are the tip of the iceberg.

Professional Athletes' misuse of anabolic steroids, growth hormone and other drugs are the tip of a very large, mostly ignored iceberg, made up of people who receive these drugs for such non-medical uses as body-building, school sports and "anti-aging". Although these drugs are often used in combination, this article focuses on growth hormone. Fuelling the demand for these drugs are drug manufacturers, pharmacies, websites, clinics and their doctors.

Esteróides anabolizantes: mecanismos de ação e efeitos sobre o sistema cardiovascular / Esteroides anabólicos: mecanismos de acción y efecto sobre el sistema cardiovascular / Anabolic steroids: action mechanisms and effects on the cardiovascular system

Esteróides androgênicos anabólicos são recursos ergogênicos comumente utilizados por atletas em busca de melhores desempenhos. Entretanto, o uso destas substâncias por indivíduos não atletas, para fins estéticos, vêm se tornando um problema crescente em academias e centros esportivos. Esta conduta tem favorecido o uso indiscriminado e abusivo destes esteróides, expondo seus usuários a riscos de saúde. Os esteróides anabolizantes são um subgrupo dos andrógenos, ou seja, compostos sintéticos derivados da testosterona, desenvolvidos para fins terapêuticos, porém, estas substâncias também passaram a ser utilizadas no esporte, com o objetivo de melhora no desempenho físico, devido a sua grande propriedade anabólica e reduzido efeito androgênico. Portanto, são as propriedades anabólicas que promovem os efeitos desejados pelos atletas, melhorando desta forma o desempenho físico. Apesar do fato de os esteróides anabolizantes exibirem possíveis melhoras no desempenho físico, doses excessivas podem trazer diversas alterações deletérias, principalmente àquelas relacionadas ao sistema cardiovascular e não tem sido incomum a associação entre o abuso no consumo de esteróides anabolizantes e o aparecimento de distúrbios cardíacos. Nesse sentido, o objetivo do presente estudo foi realizar uma revisão bibliográfica para investigar os possíveis efeitos deletérios do uso indiscriminado de esteróides anabolizantes ao sistema cardiovascular. PALAVRAS-CHAVE: Esteróides anabolizantes/efeitos adversos. Esteróides/administração e dosagem. Sistema cardiovascular

Anabolic androgenic steroids are ergogenic aids commonly used by athletes in search of better performances. However, the use of these substances by individuals who are not athletes with aesthetic aims is becoming an increasing problem in fitness and sport centers. This behavior has favored the indiscriminate and abusive use of these steroids, exposing their users to health risks. Anabolic steroids are a sub-group of androgenes, that is, synthetic compounds derived from testosterone, developed for therapeutic ends, but these substances had also began to be used in sports, with the aim of improvement of physical performance, due to their anabolic properties and reduced androgenic effect. Therefore, the anabolic properties are the substances that promote the effect desired by athletes, improving this way their physical performance. Despite the fact of anabolic steroids to cause possible improvements in physical performance, extreme doses can cause several deleterious alterations, mainly those related to the cardiovascular system and it has not been uncommon the association of abuses in of anabolic steroids consumption and the emergence of cardiac troubles. In this sense, the objective of the present study was to carry through a bibliographical review to investigate the possible deleterious effects of the indiscriminate use of anabolic steroids to the cardiovascular system. KEYWORDS: Anabolic steroids- adverse effects. Steroids-administration and dosing. Cardiovascular system

Los esteroides anabólicos androgénicos son recursos ergogénicos usados comúnmente por los atletas en la búsqueda de mejores desempeños. Sin embargo, el uso de estas sustancias por individuos que no son atletas con objetivos estéticos se está convirtiendo en un problema creciente en centros de gimnástica y de deportes. Ese comportamiento ha favorecido el uso indistinto y abusivo de estos esteroides, exponiendo a sus usuarios a los riesgos de salud. Los esteroides anabólicos son un subgrupo de los andrógenos, es decir, compuestos sintéticos derivados de la testosterona, desarrollados con finalidades terapéuticas, pero estas sustancias también comenzaron a ser utilizados en deportes, con la meta de mejoría del desempeño físico, debido a sus características anabólicas y sus efectos androgénicos reducidos. Por lo tanto, las características anabólicas de esas sustancias son las que promueven el efecto deseado por los atletas, mejorando de esta manera su funcionamiento físico. A pesar del hecho de que los esteroides anabólicos producen mejorías en el funcionamiento físico, las dosis extremas pueden causar varias alteraciones deletéreas, principalmente las relacionadas con el sistema cardiovascular, e no han sido infrecuente la asociación de abusos del consumo de los esteroides anabólicos con la aparición de apuros cardiacos. En este sentido, el objetivo del estudio es realizar una revisión bibliográfica para investigar los efectos deletéreos posibles del uso indistinto de esteroides anabólicos en el sistema cardiovascular.PALABRAS LLAVE: Esteroides anabólicos-efectos adversos. Esteróides-suministración e dosaje. Sistema cardiovascular

Growth-promotant implants: managing the tools.

Great contemplation, conversation, and controversy have surrounded the use of growth-promotant implants since their inception in the 1950s. Since the very beginning, the purpose of growth promotants has been to enhance production efficiency, reduce the cost of production, and improve profitability. Changes in our understanding of the physiologic mechanisms involved in growth promotion have not altered this fundamental purpose. With enhanced knowledge of the impact of various compounds and doses on different classes of animals, and with the introduction of numerous products providing those compounds and doses, planning implant programs has become difficult. However, the net return from a well-designed implant program may mean the difference between profit and loss on a given set of cattle.

Histological assessment of ovaries and uterus of rats subjected to nandrolone decanoate treatment.

This study aimed to analyze the effects of nandrolone decanoate on the ovaries and uterus of adult females rats. This drug was administered intraperitoneally, at one, two and three doses of 3 mg nandrolone decanoate/kg of body weight, respectively, in the first, second and third week of treatment. The females of the control group received a physiological solution. The rats treated with nandrolone decanoate showed estral acyclicity and there was destruction of follicular units and an absence of corpus luteum in the ovaries. In the uterus, the drug promoted morphological alterations, characterized by vacuolated epithelium and endometrial stroma fibrosis. Ovary, uterus and pituitary weights were not affected by the steroid treatment. Nandrolone decanoate affects the sexual cycle and promotes histological alterations in the ovaries and uterus of adult female rats.

Quantitative assessment of foetal exposure to trenbolone acetate, zeranol and melengestrol acetate, following maternal dosing in rabbits.

1. Residues of commonly used growth-promoting agents found in animal meat can be hormonally active and they have been implicated as possible endocrine disruptors in man. Although these compounds could be potentially detrimental to the developing foetus, it is not clear whether and to what extent they pass through placental barrier. 2. This issue was addressed using the rabbit as an animal model. Pregnant rabbits were treated with trenbolone acetate, zeranol or melengestrol acetate beginning at gestation day 14. Levels of active substances in plasma were screened by means of specific ELISA systems. The residues of parent compounds and their metabolites were quantified in maternal and foetal tissues on gestation day 27 using validated, sensitive HPLC/ELISA methods. 3. All three compounds crossed the placental barrier and were detectable in foetal tissues. The extent of tissue concentration varied depending on the compound and tissue analysed. Gender differences were observed in some instances.

[Body-building, steroid use, and risk perception among young body-builders from a low-income neighborhood in the city of Salvador, Bahia State, Brazil]. / Musculação, uso de esteróides anabolizantes e percepção de risco entre jovens fisiculturistas de um bairro popular de Salvador, Bahia, Brasil.

Recent studies in different countries have shown an increase in anabolic steroid consumption among young people and the harm caused by indiscriminate use. In Brazil, research on steroid abuse is scarce. The present study examines the risk perception of health problems associated with anabolic steroid consumption among young working-class adults engaged in body-building practices in a poor neighborhood in the city of Salvador, Bahia. The methodology involved an anthropological approach based on qualitative research techniques consisting of ethnography, in-depth interviews, and a focus group with steroid users. The data describe the most common substances consumed and highlight the lack of information among interviewees concerning potential related health hazards, showing that for many steroid consumers the quest for muscle-mass development to achieve an idealized body supersedes the risk of harmful side effects. The results indicate the need for culturally sensitive measures to prevent steroid abuse among youth.

Androgen-androgenic steroids, the athlete, and mortality.

Use of performance-enhancing substances is widespread among men and women athletes and body builders, professional or amateur, adolescent or adult. Many of these substances are illegal or have adverse effects. This article describes the action and effects of androgenic and growth hormones, their legality, their potential for abuse, and their impact on mortality.

Anabolic-androgenic steroids: medical assessment of present, past and potential users.

OBJECTIVE: To document adverse effects of anabolic-androgenic steroid (AAS) use in community-based users attending a medical clinic. DESIGN AND SETTING: Prospective recruitment, questionnaire-based interview, physical examination and investigations, with follow-up, of people who attended, anonymously, an inner-city hospital clinic established specifically to examine AAS use. PARTICIPANTS: 58 men, comprising 27 past AAS users, 14 present users and 17 potential users (who formed the control group). MAIN OUTCOME MEASURE: Clinical adverse effects and abnormal laboratory findings. RESULTS: Cyclical use of oral and intramuscular, human and veterinary AASs were reported. The most commonly reported source of AASs was friends (59%), gymnasiums (25%) and doctors (14%). The most common reported adverse effects were alterations in libido (61%), changes in mood (48%), reduced testis volume (46%) and acne (43%). Although mean systolic and diastolic blood pressure was not significantly different between groups, five present (29%), 10 past (37%) and one potential user (8%) were hypertensive. Gynaecomastia was found in 10 past users (37%; P<0.01 v. potential users), two present users (12%) and no potential users. Mean testis volume was significantly smaller in present users (18 mL; P<0.02) than in the other groups. Twenty past users (83%), eight present users (62%) and five potential users (71%) had abnormal liver function test results (P=0.5). After discussion of test results, only 11 participants (19%) reported they would not use AASs in the future. CONCLUSIONS: Adverse effects were reported by or detected in most of the AAS users who attended the clinic. Despite awareness of adverse consequences, most participants planned future use of AASs.

Use, misuse and abuse of androgens. The Endocrine Society of Australia consensus guidelines for androgen prescribing.

Androgen replacement therapy (ART) is usually life-long, and should only be started after androgen deficiency has been proven by hormone assays. The therapeutic goal is to maintain physiological testosterone levels. Testosterone rather than synthetic androgens should be used. Oral 17 alpha-alkylated androgens are hepatotoxic and should not be used for ART. There is no indication for androgen therapy in male infertility. Although androgen deficiency is an uncommon cause of erectile dysfunction, all men presenting with erectile dysfunction should be evaluated for androgen deficiency. If androgen deficiency is confirmed, investigation for the underlying pathological cause is required. Contraindications to androgen therapy are prostate and breast cancer. Precautions include using lower starting doses for older men and induction of puberty. Intramuscular injections should be avoided in men with bleeding disorders. Androgen-sensitive epilepsy, migraine, sleep apnoea, polycythaemia or fluid overload need to be considered. Competitive athletes should be warned about the risks of disqualification. ART should be initiated with intramuscular injections of testosterone esters, 250 mg every two weeks [corrected]. Maintenance requires tailoring treatment modality to the patient's convenience. Modalities currently available include testosterone injections, implants, or capsules. Choice depends on convenience, cost, availability and familiarity. There is no convincing evidence that, in the absence of proven androgen deficiency, androgen therapy is effective and safe for older men per se, in men with chronic non-gonadal disease, or for treatment of non-specific symptoms. Until further evidence is available, such treatment cannot be recommended.

Economic impact of tibolone compared with continuous-combined hormone replacement therapy. In the management of postmenopausal women with climacteric symptoms in the UK.

OBJECTIVE: To estimate the economic impact of using tibolone 2.5 mg compared with 17 beta-estradiol 2 mg/norethisterone acetate 1 mg (E2/NETA) in postmenopausal women with climacteric symptoms. DESIGN AND SETTING: This was a modelling study performed from the perspective of the UK's National Health Service (NHS). METHODS: The clinical outcomes from a previously reported trial were used as the clinical basis for the analysis, which showed that 48 weeks' treatment with tibolone and E2/NETA significantly alleviated the climacteric symptoms experienced by postmenopausal women. These data were combined with resource utilisation estimates derived from a panel of 10 GPs and 3 gynaecologists, enabling us to construct a Markov model depicting changes in the health status of postmenopausal women. The model was used to estimate the expected NHS costs and consequences after 48 weeks' treatment with tibolone and E2/NETA. MAIN OUTCOME MEASURES AND RESULTS: The mean expected direct healthcare cost of using tibolone and E2/NETA to manage postmenopausal women for 48 weeks was estimated to be 260 Pounds and 239 Pounds (1997/1998 prices) per patient, respectively. Starting hormone replacement therapy (HRT) with tibolone instead of E2/NETA was equally effective in alleviating climacteric symptoms (65.9 and 62.2%, respectively; p = 0.516) over 48 weeks and significantly reduced the incidence of vaginal bleeding by 36% (p < 0.0001) and breast tenderness by 57% (p < 0.0001) for a mean additional cost of 21 Pounds (ranging between -3 Pounds and 42 Pounds) per patient. The acquisition cost of HRT was the primary cost driver for tibolone-treated patients, whereas the cost of managing adverse events was the primary cost driver for E2/NETA-treated patients. CONCLUSIONS: The true cost of prescribing tibolone and E2/NETA is impacted on by a broad range of resources, not only drug acquisition costs. Although the acquisition cost of tibolone is higher than that of E2/NETA, the difference in the expected NHS cost of the first year of treatment between the 2 HRTs is negligible. This is because of the higher incidence of adverse events among E2/NETA-treated patients, which also results in a higher continuation rate among tibolone-treated patients. Factors such as patient preferences should also be taken into consideration so that treatment choices are not decided solely on the basis of acquisition costs.