Androgen abuse is common amongst high-performance athletes.  Androgens are anabolic; they increase muscle mass and maximum voluntary strength.  They are taken directly (natural or synthetic androgens) or induced to rise indirectly (estrogen blockers, androgen precursors, gonadotropins).  Adverse effects are common.  In men, androgen abuse can cause testicular atrophy, reduced spermatogenesis, gynecomastia, mood disturbances, and aggressive behavior.  In women, androgens can cause acne, hirsutism, deepening of the voice, and menstrual irregularities.  Laboratory findings include erythrocytosis, hepatotoxicity, and dyslipidemia.  The mechanism for erythrocytosis in androgen abuse remains unclear, but increases in hematocrit and hemoglobin are dose dependent.  This patient is likely abusing androgens in preparation for his upcoming football season.

(Choice B)  An autologous blood transfusion involves removing blood several weeks before a competitive event and then transfusing the blood back into the athlete prior to the event.  The net effect is increased hematocrit, oxygen-carrying capacity, and performance.  However, this process typically does not cause gynecomastia or mood changes, as seen in this patient.

(Choice C)  Self-injection of erythropoietin (EPO) stimulates the bone marrow to produce more red blood cells, thereby increasing the hematocrit.  Gynecomastia, aggression, and mood changes are atypical in EPO abuse; they are much more common with androgens.  EPO is primarily abused by athletes participating in endurance sports.

(Choice D)  An intensive exercise schedule usually increases muscle mass, improves muscle function, and enhances exercise capacity.  Erythrocytosis is not a typical consequence of a strenuous exercise regimen.

(Choice E)  Polycythemia vera (PV) is a chronic myeloproliferative disorder that causes erythrocytosis.  It is often asymptomatic, but aquagenic pruritus (itching after a warm bath or shower), bleeding, transient neurologic symptoms, and erythromelalgia (burning cyanosis of the hands or feet) are common presenting symptoms.  Gynecomastia, irritability, and aggression are more suggestive of androgen abuse than PV.

Educational objective:
Competitive athletes using exogenous androgens, autologous blood transfusions, or erythropoietin to enhance athletic performance can develop an elevated hematocrit.  Clinical findings suggesting exogenous androgens include gynecomastia, testicular atrophy, mood disturbances, and hepatotoxicity.