May 24, 2019
Case report: The long‐term effects of anabolic steroids on the female voice over a 20‐year period
Key Clinical Message
Anabolic steroids and androgenic steroids (AAS) can have long‐term effects on the female voice. These changes are clinically relevant since they are difficult to treat and therefore should be disclosed to patients using AAS or receiving androgenic steroid therapy.
1 INTRODUCTIONA 27‐year‐old female bodybuilder presented with an androgenized voice (F0 = 110 Hz) after 6 weeks of androgenic anabolic steroid. She was followed for 20 years, requiring multiple surgical interventions to increase her pitch and presented with delayed severe vocal fold atrophy, with concurrent abnormal low testosterone levels. Androgenic anabolic steroids (AAS) can have virilizing effect in women. The most common side effects include weight gain, acne, and increased libido, which are usually reversible. However, the masculinized voice change associated with AAS, including decreased pitch, reduced F0, and vocal fold thickening, has been reported as irreversible1, 2 despite discontinued use. A new entity, anabolic steroid‐induced hypogonadism (ASIH), described by Jarow,4 suggests AAS can have an inhibitory effect on the hormonal axis long after discontinuing their use, including hypotestosteronism. Several authors have since described this condition in men,5but there has been no reported case of ASIH in woman or description of vocal symptoms due to this condition. This is a case report on the effect of AAS in a 27‐year‐old woman who ingested AAS when competing as a bodybuilder. This patient experienced disabling side effects due to androgenization of her voice and required surgery to increase vocal pitch in order to be identified as female. She has been followed for 20 years and experienced further unanticipated changes in vocal function many years after discontinuing anabolic steroid use, concurrently with abnormally low testosterone levels.
2 CASE REPORTK. A, a 27‐year‐old woman, formerly a bodybuilder, sought treatment at our tertiary voice center for “masculine” voice in 1998. The patient had developed a gradual husky and low‐pitched voice change over a period of months, two years prior to presentation (at presentation—VHI = 40, F0 = 110 Hz, Jitter = 0.64%, Shimmer = 2.6%, pitch range = 2 semitones). The patient was more often than not perceived as male, and the gender misidentification was disabling in her personal and professional life including the loss of employment due to her voice quality. The patient had taken nandrolone, 50 mg/wk for 6 weeks as part of a muscle enhancement bodybuilding program. The voice change developed within 8 weeks of starting the androgenic steroids, and despite discontinuing the drug, the voice did not improve. No other previous voice issues or general health problems were reported. The patient was no longer bodybuilding and denied any other hormone replacement or medical therapy. She was fully evaluated by an endocrinologist (at presentation, normal female hormone profile) and was followed long‐term by her specialist. Videostroboscopy at initial evaluation showed thick vocal folds, with blunting of the free edge bilaterally. A dull pink color was noted throughout the full length of the membranous vocal folds. There was no glottis gap with mucosal wave present bilaterally (Figure 1). Mild aperiodicity was also noted, and the fundamental frequency (F0) was 110 Hz, clearly in the lower range for a male and below the normal range for females.
The patient underwent bilateral type 1 medialization thyroplasty (MT) under local anesthetic with silastic blocks to augment vocal fold mass (2015), which resulted in a significant improvement in vocal function reflected by an reduction in her VHI. Hormonal serum values for patient K.S from 2008 to 2016
|Date||TSH (U/mL)||TT (nmol/L)||FT (pg/mL)||DHEA (nmol/L)||SHBG (nmol/L)||LH (U/L)||FSH (U/L)||PrL (ng/mL)|
- DHEA, dehydroepiandrosterone (normal range: 1.8‐7.7 nmol/L); FSH, follicular‐stimulating hormone; FT, free testosterone (normal range: 0.3‐6.9 pg/mL); LH, luteinizing hormone; SHBG, sex hormone‐binding globulin (normal range for adult female: 20‐180 nmol/L); PLC: prolactin (normal range for nonpregnant female: <26 ng/mL); TSH, thyroid‐stimulating hormone (normal range: 0.3‐5.0 U/mL); TT, total testosterone (normal range: <1.8 nmol/L). All values since 2008 were taken after more than 9 y of withdrawal from AAS. The year of 2012 coincides with the patient presenting back to our clinic 13 y later with vocal fold atrophy.