Differentials
Use of other ergogenic compounds
SIGNS / SYMPTOMS
History of taking alternative ergogenic compound; patients may also currently use, or have previously used, anabolic-androgenic steroids.[50]
Other ergogenic compounds include anti-oestrogens (e.g., tamoxifen, clomifene, raloxifene, toremifene, droloxifene), aromatase inhibitors (e.g., aminoglutethimide, testolactone, atamestane, exemestane, anastrozole, letrozole, vorozole), oestrogen precursors (e.g., dehydroepiandrosterone [DHEA], androstenedione), and the gonadotrophins (e.g., LH, human chorionic gonadotrophin).[50]
INVESTIGATIONS
Specific mass spectrometry testing is required to identify these compounds.[50]
Polycystic ovarian syndrome (PCOS)
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
Hyper-androgenism.
Depending on culture and ancestry, 30% to 80% of women with PCOS are overweight or obese, with central obesity (waist-to-hip ratio >0.85 or waist circumference >88 cm).
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Pelvic ultrasound shows polycystic ovaries.
Glucose tolerance test shows insulin resistance.
Drug-induced hirsutism
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
History of taking drugs known to cause hirsutism including minoxidil, phenytoin, danazol, or diazoxide.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Gas chromatography/mass spectrometry detection of exogenous drugs may confirm diagnosis.
Cushing's syndrome
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
History of intake of glucocorticoids.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Elevated serum cortisol level.
High 24-hour urine cortisol excretion.
Positive dexamethasone suppression test (persistently high cortisol after giving dexamethasone).
Precocious puberty
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
Lack of masculinisation effects (ovarian and central precocious puberty).
Lack of feminisation effects (testicular and central precocious puberty).
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Gonadotrophin-dependent precocious puberty tends to have both elevated LH and elevated FSH, both of which increase after taking exogenous gonadotropin-releasing hormone (GnRH).
Gonadotrophin-independent precocious puberty patients have low levels of FSH and LH, and these hormones do not rise after GnRH dosing.
Congenital adrenal hyperplasia
SIGNS / SYMPTOMS
Typically presents in infancy.
No history of taking anabolic-androgenic steroids in patients with late-onset disease.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Elevated serum 17-hydroxyprogesterone demonstrates deficiency of 21-hydroxylase.
Adrenal neoplasm
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
MRI of abdomen/pelvis typically appears hyper-intense to the liver on T2-weighted images because of their high water content.
Appear on CT scan as inhomogeneous masses, often with a central area of low attenuation that represents haemorrhage or necrosis.
Anorexia nervosa
SIGNS / SYMPTOMS
May co-exist with anabolic-androgenic steroid (AAS) use disorder.
No history of taking AASs.
Patients often believe they are overweight.
Lack of muscle bulking.
Low daily calorie count.
INVESTIGATIONS
Negative urine test for AASs.
Drug-induced jaundice
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
History of taking drugs known to cause jaundice including oral contraceptives, ethanol, or isoniazid.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Gas chromatography/mass spectrometry detection of exogenous drugs may confirm diagnosis.
Haemolytic anaemia
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
Symptoms develop rapidly.
Tachycardia and pallor.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Decreased haemoglobin level and haematocrit with high reticulocyte count.
Increased serum bilirubin concentration.
Cholelithiasis
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Gallstones occasionally seen on plain x-ray or CT, and reliably identified with ultrasound.
Hepatitis
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
History of sharing needles, intercourse with infected partner, or travel exposure (viral hepatitis).
History of taking drugs/toxins known to cause hepatitis including paracetamol, valproate, troglitazone, mushrooms, pennyroyal, or carbon tetrachloride (drug-induced hepatitis).
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Elevated indirect bilirubin.
Positive hepatitis serology.
Toxicology testing may detect drugs or other substances that induce hepatitis (drug-induced hepatitis).
Cirrhosis
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
History of chronic alcohol ingestion.
Liver feels firm and nodular on examination.
Ascites.
Splenomegaly.
Clubbing.
Spider angiomata.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Liver biopsy demonstrates architectural distortion of the liver parenchyma with formation of regenerative nodules.
Prolonged prothrombin time and decreased platelet count.
Hepatic malignancy
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
Anorexia and weight loss.
Lack of muscle bulking.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Liver biopsy demonstrates malignancy.
Ovarian cancer
SIGNS / SYMPTOMS
No history of taking anabolic-androgenic steroids.
Anorexia and weight loss.
Lack of muscle bulking.
INVESTIGATIONS
Negative urine test for anabolic-androgenic steroids.
Pelvic ultrasound shows presence of solid, complex, septated, multiloculated mass and high blood flow.
CT scan shows peritoneal thickening, enlarged lymph nodes, ascites, omental thickening, or liver metastases.
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