A 22-year-old woman comes to the office due to feeling depressed over the last 10 days. She says, "The other day, I just started crying for no reason. I really should feel good because I work out in the gym every day. But I just don't feel like doing anything else. I can't shake this feeling." The patient has also felt more irritable in the past week. "I almost got into a fight with a woman in the gym. I can be sad one minute and angry the next; it's weird." She has a history of an eating disorder as a teenager as well as attention-deficit/hyperactivity disorder. The patient has no other medical problems except for acne, which recently worsened. She has 4 or 5 alcoholic drinks a week. Her only medication is methylphenidate, and the prescribed dose has remained stable over the past few years. The patient has a family history of depression. Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min. Mental status examination shows no abnormalities. Physical examination is notable for facial acne and mild hirsutism. Chemistries and complete blood count are within normal limits except for mildly elevated hematocrit and hemoglobin. Which of the following is the most likely explanation for this patient's symptoms?

Question

A 22-year-old woman comes to the office due to feeling depressed over the last 10 days.  She says, "The other day, I just started crying for no reason.  I really should feel good because I work out in the gym every day.  But I just don't feel like doing anything else.  I can't shake this feeling."  The patient has also felt more irritable in the past week.  "I almost got into a fight with a woman in the gym.  I can be sad one minute and angry the next; it's weird."  She has a history of an eating disorder as a teenager as well as attention-deficit/hyperactivity disorder.  The patient has no other medical problems except for acne, which recently worsened.  She has 4 or 5 alcoholic drinks a week.  Her only medication is methylphenidate, and the prescribed dose has remained stable over the past few years.  The patient has a family history of depression.  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min.  Mental status examination shows no abnormalities.  Physical examination is notable for facial acne and mild hirsutism.  Chemistries and complete blood count are within normal limits except for mildly elevated hematocrit and hemoglobin.  Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

Explanation: This patient's changes in mood, worsened acne, and hirsutism suggest the likelihood of anabolic-androgenic steroid abuse. Anabolic steroids (eg, testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve physical appearance and performance. In women, they may also be associated with eating disorder symptoms; in addition, women may exhibit clitoromegaly, bilateral temporal hair loss, and an irreversible deepening of the voice. Mood symptoms may occur in both women and men. Increased aggressive behavior can also be seen (more notably in men). Other adverse effects include impaired endogenous testicular function, decreased testicular size and sperm count, and gynecomastia in men, as well as ovarian dysfunction in women. Hepatic dysfunction may occur, HDL levels can decrease, and high doses can cause cardiac dysfunction. In addition, patients can develop erythrocytosis due to androgen-stimulated erythropoiesis; erythropoietin used to enhance athletic performance can also increase erythropoiesis but does not cause androgenic hormonal changes (Choice C). (Choices B and D) Primary mood disorders are not diagnosed if symptoms are attributable to substances (eg, anabolic steroids). Cyclothymic disorder is characterized by numerous periods of hypomanic and depressive symptoms that occur over at least 2 years. A major depressive episode involves >2 weeks of persistently depressed mood and associated depressive symptoms (eg, sleep and appetite disturbance, decreased energy and concentration, suicidality). This patient's mood changes have been present for 10 days. (Choice E) Methylphenidate is a central nervous system stimulant used for attention-deficit/hyperactivity disorder. It is associated with hypertension and tachycardia and, when misused, may result in agitation, aggressiveness, and psychosis. However, this patient's hirsutism (virilization) and depressed mood are more likely explained by anabolic steroid abuse. Educational objective: Anabolic-androgenic steroids are used to improve physique and athletic performance but are associated with numerous adverse effects, including mood and behavior changes. Findings may include acne, hirsutism, bilateral temporal hair loss, voice deepening, gynecomastia, clitoromegaly, testicular failure, ovarian dysfunction, hepatic dysfunction, altered lipid profiles, and erythrocytosis. References: Mechanisms in endocrinology: medical consequences of doping with anabolic androgenic steroids: effects on reproductive functions. (http://www.ncbi.nlm.nih.gov/pubmed/25805894) Effects of anabolic androgenic steroids on the reproductive system of athletes and recreational users: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28258581)

A 22-Year-Old Woman Comes to the Office Due to Feeling