Evaluating the Real Health Risks of Anabolic Steroids

Anabolic Steroid Use by Women and Teenagers 
Without question, there are health risks involved in the self-administration of any prescription medicine, particularly in the absence of a physician's advice with respect to dosages and duration of use. Further, without regular monitoring by a doctor, some side effects may go unnoticed or untreated until it is too late. Anabolic steroids can have adverse effects upon the body, and the risks for teenagers and women are higher than for adult males. Since large exogenous doses of androgens are more foreign to a woman's body than to a man's, their effect on the delicate hormonal balance of a woman is more profound. Excessive growth of body hair (hirsutism), coarsening of the skin, male pattern baldness, and deepening of the voice may occur (especially at massive dosages) and are generally not reversible upon discontinuance of steroids. Other possible effects particular to women include heavy facial masculinization, breast tissue reduction, alterations in menstrual cycles, and clitoral enlargement. Legal issues aside, any woman considering the use of high-dose androgens for physical enhancement must seriously weigh the perceived benefits against the quite unappealing potential cosmetic costs. 

For teenagers, there is the additional risk of premature closure of the growth plates of the long bones. Even if not for this added risk, the self-administration of anabolics by teenagers must be strongly discouraged. As compared to mature adults, teenagers are much more likely to abuse anabolic steroids to the possible detriment of their health. Generally less focused upon long-range health than adults, more susceptible to peer pressure, and eager for fast results, teenagers are more likely to use anabolics in dangerously high dosages and without any medical supervision. Also, as it is recognized that the effects of anabolics upon size and strength are partially (and sometimes even completely) temporary, teens seem particularly less willing to suffer these post-cycle size and strength reductions, and are more likely to continuously use high-dose steroids for prolonged periods. Even Dan Duchaine, author of the Underground Steroid Handbook II (1989) and a favorite target of the proponents of steroid criminalization, is opposed to steroid use by teenagers. Clearly, even in countries where steroids can be legally obtained without a prescription, it is this writer's opinion that the choice to use them for physical enhancement should be made by mature, informed adults with a pre-established dedication to serious weight-training for several years. Anabolic steroids should never be used by beginning lifters, those with dubious commitments to weight-training, or those simply seeking a substitute for hard work. Parents with suspicions or concerns about their teen children experimenting with anabolics should see Wright & Cowart (1990), Chapter 4, "Recognizing Anabolic Steroid Use in Adolescents," pp. 71 -91. [But as strongly as the juvenile use of anabolics should be discouraged, there is a major question as to whether our nation's present "criminalization" approach is working. See, Do Our Anabolic Steroid Laws Work? section.] 

Adverse Effects of Excess Androgens 
The average adult male production of testosterone is less than 10 milligrams (mg) per day. Supplemental androgens can raise blood androgen levels to many times the amount that could be naturally produced. All these extra androgens will effect the body's hormonal balance, including the reproductive system. Because anabolics mimic endogenous androgens (i.e., your own natural testosterone) in the negative feedback loop of the hypothalamic-pituitary-gonadal axis, they cause the body to decrease its own production. Exactly how long it takes for the body to begin to shut down its own production of androgens is uncertain, although some have estimated it at about three weeks of steroid therapy. This induced hypogonadal state is characterized by decreased serum testosterone levels, associated testicular atrophy, and impaired sperm production that results in temporary infertility. It is this aspect of anabolic therapy that has been the focus of numerous studies testing the use of anabolics as a form of male contraception. But it is important to note that these effects are reversible with discontinuance of the steroids (Haupt and Rovere, 1984, p. 481), and that no case of permanent sterility as a result of prolonged high-dose steroid consumption has ever been reliably documented (Yesalis and Cowart, 1998, p. 53). 

Steroid use can also effect the libido. It is common for the sex drive to heighten during a cycle but decrease toward the end and after because the body's own production of testosterone has been temporarily shut down due to the exogenous steroids. Decreased testicular size is also not uncommon with prolonged usage. Both of these adverse effects are reversible upon the body's own recuperation and often can be avoided altogether with the administration of gonadotropin stimulating drugs, which "jump-start" the body's natural production of testosterone (Phillips, 1991, p. 131; Di Pasquale, 1990, pp. 24-26). 

Other adverse effects of excessive androgens upon the body's system of hormones are primarily due to the eventual conversion of the androgens into other compounds. Earlier, we noted that steroid molecules in the body are eventually converted into other compounds or excreted in the urine (see How do Anabolic Steroids Work in the Body? section). Testosterone can be converted by an enzymatic process into a slightly altered derivative hormone called dihydrotestosterone (DHT), a steroid molecule that may be significantly responsible for these adverse effects. Adverse effects of an androgenic nature occur because muscles are not the only parts of the body with receptor sites for steroid molecules, and because a steroid molecule has the potential to deliver several different messages. Which message the steroid molecule delivers depends upon the location of the receptor site to which it links. A steroid molecule linking to a receptor site in a hair follicle may deliver a message to stop growing (leading to male pattern baldness). One linking to a site in a sebaceous gland may deliver a message to produce more oil (leading to acne). One linking to a site in the prostate gland may deliver a message for the gland to enlarge (leading to prostatitis). The occurrence and extent of these adverse effects depend upon the concentration of receptor sites for steroid molecules in that particular area. Each individual is different. For example, male pattern baldness can be exacerbated in athletes who have a genetic predisposition. Steroids with a high conversion rate to DHT seem to be particularly responsible for this adverse effect, and should be avoided. Also, the effect can be partially controlled by the use of finasteride (Proscar or Propecia), a prescription drug which helps to block the conversion of testosterone to DHT. 

The appearance of androgenic effects is also largely related to the dosage and to the choice of steroid. Highly androgenic steroids such as testosterone esters, especially in very large doses, will generally be much more prone to cause problems than highly anabolic, less androgenic drugs like methenolone or oxandrolone. However, recent research suggests that the side effects of even highly androgenic compounds have been overstated. There were no significant side effects of 10 weeks of testosterone enanthate at a dosage of 600 mg per week (six times the replacement dose of this highly androgenic ester and more than many bodybuilders might use) (Bhasin,et al.). (In a discouraging kick in the pants to natural athletes everywhere, study participants receiving the testosterone injections without any exercise at all enjoyed significantly greater increases in fat-free mass, arm size and leg size than those who worked out hard but without the steroids.) Other studies have also reported minimal significant androgenic side effects (Pope & Katz, 1994), including one involving the highly androgenic oral steroid oxymetholone (Hengge, et al.). Androgens also have the capacity to be converted into estrogen by chemical reactions and enzymes within certain body tissues. The process by which the steroid molecule is converted to estrogen is called aromatization. Those anabolics that are easily aromatized into estrogen can cause a feminization of the breast tissue known as gynecomastia. While largely dose related, a natural propensity for this condition can cause it to occur even in moderate dosages. This condition can often be avoided or arrested by the judicious use of anti-estrogenic compounds. Once a serious cosmetic problem exists, minor surgery is required to correct it. Numerous professional bodybuilders have had this surgery (Phillips, p. 125) and others obviously need it (look closely at a very top place finisher in the 1998 Mr. Olympia lineup). 


Anabolic Steroids and the Liver 
Anabolic steroids are processed by the liver. As discussed earlier, C-17 alkylated oral steroids (steroids with an alkyl group added at the alpha position of the "C-17" or number 17 carbon atom of the molecule to withstand total degradation on their first pass through the liver [see Steroids 101 section above]) are unusually harsh on the liver. For this reason, even moderate short-term administration of these C-17 oral steroids can effect liver function test readings. Elevated liver counts indicating liver stress (toxicity) have been reported in recent studies of somewhat moderate oral anabolic steroid therapy (daily doses of 40 and 80 mg of oxandrolone [Oxandrin, formerly Anavar]) as reported in the online periodical Medibolics, edited by Michael Mooney (www.medibolics.com). However, these elevated liver function readings will return to normal after cessation of a moderate, short-term steroid cycle. I could find not one case to the contrary. Further, it is recognized that intense weight training alone often causes changes in liver function tests, including SGOT, SGPT and LDH (this is something that all physicians monitoring athletes using anabolics should be familiar with). 

The more serious liver problems attributed to anabolic steroid use include hepatocellular carcinoma (liver cancer) and peliosis hepatitis (blood-filled sacs within the liver). But the majority of cases reporting liver problems have dealt with extremely sick and elderly patients treated with C-17 alkylated oral steroids for years of continuous use, and many of these patients had a particular type of anemia linked to liver tumors even without anabolic steroid therapy. A computer search of the medical literature looking for steroid-associated liver tumors could find only three in athletes (Friedl, 1990). Of the three athletes, one was using 700 mg of oxymetholone a week for five straight years, and one had a tumor more indicative of classic liver cancer than of steroid-associated tumors. Virtually all of the reported liver problems seemed to occur with the 17 alpha-alkylated oral steroids. There have been no cysts or liver tumors reported in athletes using the 17 beta-esterified injectable steroids (Wright & Cowart, p. 61). It has been noted that injectable steroids generally appear to have little effect on the liver at all (Haupt, 1993, p. 469). 

Recent studies continue to suggest that reports of serious adverse effects of anabolic steroids upon the liver in healthy athletes may be highly overstated. In a study of athletes, of the 53 current or past steroid users who underwent laboratory testing, only one subject displayed an abnormal liver test (Pope & Katz, 1994, p. 379; incidentally, on physical examination, not one user displayed evidence of any major abnormalities possibly attributable to steroids, such as high blood pressure, edema, acne or hair loss.) Another study tested one of the most powerful and reputedly dangerously toxic anabolic steroids for 30 weeks on HIV positive men and women (Hengge et al.). Oxymetholone, formerly known as Anadrol in the U.S. and a C-17 alkylated oral steroid, was administered in a dosage of over 1,000 mg per week (more than that used by many bodybuilders, and for a much longer duration of uninterrupted use). The results were significant gains in lean muscle mass -- even without any weightlifting. Even more importantly - and surprisingly -- there were no significant problems with liver function, water retention, or virilization side effects (it will be interesting to see whether further studies yield consistent findings at such high dosages). 

While the dangers of anabolics to athletes' livers appear to have been highly exaggerated, it must be recognized that an apparently healthy athlete with a previously existing but undiscovered liver problem could do serious damage to himself by self-administering C-17 oral anabolic steroids. For this reason alone, it would be quite irresponsible for any athlete to use anabolic steroids without having a physician regularly conduct blood tests to monitor liver function.



Anabolic Steroids and the Heart 
How cardiac risk might be increased by the use of steroids is a subject of speculation and some controversy. High blood pressure is perhaps "one of the most exaggerated claims" of steroid-related health risks, and remains unconfirmed despite numerous studies (Friedl, 1993, pp. 119-120). Regarding blood lipid levels, oral steroids in particular seem to cause a reduction in HDL (high-density lipoprotein cholesterol) levels in some steroid users. However, changes in the blood lipid levels now appear to begin to recover within about a month after discontinued use, and, in fact, most studies do not report an increase in total cholesterol (Yesalis & Cowart, p. 54). 

In examining cardiovascular risks, often cited is a case report by (R.A. McNutt, et al, 1988), concerning a 22-year-old steroid-using weightlifter who experienced a sudden heart attack. While often held out by anti-steroid authorities as the "smoking gun" connecting steroid use to heart attacks, a reading of the actual report reveals that the subject weighed 330 pounds and had a total serum cholesterol of a whopping 596 mg/dl! The fact that so few similar case studies exist may well indicate that the condition of this individual was hardly representative of the majority of athletes who use steroids. (Nonetheless, all strength athletes, including steroid users, should regularly monitor serum cholesterol. Obviously, this poor fellow didn't get his cholesterol to 596 overnight, and it is not reported when he last visited a physician prior to his heart attack. To what extent our nation's criminalization approach to steroids, which discourages steroid-users from seeing doctors, contributed to this result is open to speculation.) 

While the question of whether short-term, reversible alterations of these cardiac risk factors are detrimental to long-term cardiac health is "unanswered" at this time (Haupt, p. 469), it has been suggested that some characteristics of steroid-users - intense exercising, low body fat, and avoidance of smoking -- tend to put them in a low-risk group for heart disease (Friedl, 1993, p. 120). 

Based on our present information, cardiac risks seem to be primarily related to high dosages in the absence of physician monitoring. Jose Antonio, PhD., a nationally recognized authority on drugs in sports who has written a monthly column for Flex magazine, cites a study examining serious cardiovascular side effects in four weightlifters using "massive amounts" of steroids (Antonio, 1998). While there is little doubt that the health problems of these men were caused by their anabolic steroid abuse, these were clearly mega-dose abusers. "[H]igh dose equals high risk," notes Dr. Antonio, but "low-dose androgens (e.g., 200-600 mg per week for 10 weeks) pose little threat to health." 


Anabolic Steroids and the Prostate 
A legitimate concern is the potential adverse effect of excessive androgens on the prostate gland. While there is one case report of prostate cancer in a bodybuilder (Roberts & Essenhigh, 1986), no studies have shown an increased risk or incidence of prostatic cancer or hypertrophy with androgen use or indicated that androgens per se predispose to these conditions (Swerdloff & Wang, 1993). Numerous male contraceptive studies using up to 200 mg/week for over a year show no evidence of prostate stimulation. Researchers at the University of Iowa recently examined the prostate effects of the administration for 15 weeks of up to 500 mg/week to healthy men in their twenties and thirties (Cooper, et al., 1998, pp. 441-43). No changes in prostate size or serum prostate specific antigen (PSA) levels were detected either during or up to 25 weeks after the last dose. Further, androgens are not the only or even the main causative factor in prostate cancer, as evinced by a case study in which a chronically testosterone deficient man developed prostate cancer (Boccon, 1991, et al.). Warning: this does not necessarily mean that much higher dosages, especially of highly androgenic compounds, might not adversely effect the prostate, especially in older men. It is not known if athletes who have used steroids for prolonged periods will encounter more prostatic problems as they age (Di Pasquale, 1990, p. 62). 


Anabolic Steroids and Aggressive/Psychiatric Symptoms 
Enormous media attention has been focused upon the reported adverse psychiatric effects (especially violent behavior) of steroid use. "Roid rage" is the descriptive term for steroid-induced "spontaneous, highly aggressive, out-of-control behavior where the police either were called or should have intervened" (Yesalis & Cowart, p. 60). A few researchers have suggested that psychiatric symptoms including increased aggression are a common side effect of anabolic steroid use. For example, a flawed 1988 study suggested that psychiatric disorders occur with unusual frequency among athletes using anabolics (Pope & Katz, 1988, pp. 487-490). But the conclusions of these researchers have been regarded with skepticism by other experts (see, Lubell, 1989, comments of Dr. James Wright and Dr. Charles Yesalis at 178). "If this phenomenon is real, it is relatively rare (probably less than 1 percent) among steroid users. Even among those affected, the impact of previous mental illness or abuse of other drugs is still unclear" (Yesalis & Cowart, p. 60). "Some long-time steroid users have never suffered any emotional instability, or anything more than transient physical effects" and many steroid users describe non-violent feelings of euphoria, well-being and enhanced self-confidence as common effects (Wright & Cowart, p. 51). In one study to determine the psychiatric effects of steroid use on athletes, no significant differences could be found between users and non-users. "The facts that steroids have been used by tens of thousands if not hundreds of thousands of athletes over two decades and that behavioral effects are only recently being discovered (in small numbers) tend to support [that feelings of aggression may not be observed in the majority of steroid users]. Our findings are compatible with and complementary to those in anecdotal reports and data from individual psychiatrists" (Bahrke, et al., 1990, pp. 834-835). The researchers do not rule out, however, the possibility that in a small minority of predisposed individuals, "steroid use may be sufficient to push them over the edge and contribute to irrational or violent behavior." Many experienced steroid users have found that steroids enhance certain preexisting personality problems. Angry and combative users will become angrier and more combative; however, while normal guys will train more aggressively, they won't generally become violent. 

Not surprisingly, when psychiatric problems do occur in study subjects, there seems to be a direct correlation between dosage and prevalence of syndromes. For example, no significant psychiatric effects have been noted where reported mean weekly dosage was 318 mg (heaviest user was 620 mg/wk) (Bahrke, et al., 1992, p. 717). But where reported dosage exceeded 1,000 mg/wk, 11 out of 25 subjects (44%) exhibited mood disorders (Pope & Katz, 1994, p. 380). While, based on this and other studies, there is a dose-related correlation between steroid use and psychiatric effects, it must be noted that not all steroid users exhibit such symptoms; in fact, nearly 90% of light and moderate dosage users in this particular study exhibited no mood disorder symptoms at all. 

The psychiatric effect that massive amounts of anabolics might have upon predisposed individuals has created a new defense in criminal cases (see, Lubell). Just as voluntary alcohol intoxication can be used to negate the specific intent required for certain crimes, so has voluntary ingestion of anabolic steroids been offered in the defense of various violent crimes in an effort to prove that the accused was unable to distinguish right from wrong or to understand the consequences of his acts. A sampling of these cases reveals, generally, that such defenses were unsuccessfully raised. This may be due in part to the fact that in many cases the dosages administered were either not specified or were too low to be persuasive. A bigger factor may be the general reluctance of juries to acquit in murder cases based on insanity defenses, especially where the insanity was caused by a voluntarily consumed substance. 

Anabolic Steroids and Psychological Dependence 
There is some evidence that anabolic steroid use can lead to psychological dependence in certain individuals. Whether the dependence is due to chemical effects upon the brain or simply because of the positive reinforcement occasioned by a more muscular physique is not known. Whatever the cause, this may be the most dangerous aspect of steroid use for those it affects. The cessation of steroid use, especially after a prolonged cycle, often leaves the user in a state of low endogenous testosterone levels. For individuals with an inadequate sense of self, the loss of some portion of the steroid gains can be psychologically devastating to the ego. These individuals can be unable to resist immediately resuming steroid use. Further, as the goal of hardcore bodybuilders is not optimal muscle size, but maximal muscle size, dosages can become excessive. While many athletes successfully use steroids intermittently and with moderation, it is a sobering thought that there are certain individuals who start out on low risk, short-term cycles and ultimately end up using massive dosages for years of uninterrupted use. It might be theorized that the problem of dependence on steroids by certain bodybuilders has less to do with the nature of the substance than with the psychological profile of the users. 

Other Adverse Effects of Anabolic Steroids 
Connective tissue injuries. The medical literature regarding the suggestion of increased athletic injuries caused by anabolic steroid use is scant (Di Pasquale, August 1992, pp. 12-13). It is not unreasonable to expect muscle and tendon tears in hardcore strength athletes, regardless of steroid use. However, the exceptional frequency and severity (often requiring surgical reattachment) of such injuries in professional level bodybuilders do raise suspicions as to the possibility that steroids, diuretics, or other drugs may be implicated. Former Mr. Olympia Dorian Yates has suffered training-related injuries to the chest, leg and biceps, and retired after a major triceps injury. Pro bodybuilder Alq Gurley reportedly completely tore the quadriceps muscles in both legs when he fell while simply walking! Whether these injuries are steroid-related is as yet unknown, although some animal studies have suggested that steroids may cause tendon degeneration and increased risk of tendon rupture. It may not be unreasonable to assume that, like many adverse steroid effects, connective tissue injuries are mostly associated with high-dose, prolonged usage. 

AIDS. Many articles include this as a possible consequence. Quite frankly, anyone who would even consider sharing needles with his gym buddies in this day and age is so irresponsible and judgment-impaired that the substance of this entire article is lost on him. 

Premature Closure of Growth Plates. Chronic steroid usage prior to puberty or in early adolescence can cause premature closure of the growth plates of the long bones, preventing the young user from attaining full natural height. For this reason as well as others previously discussed, teenagers should not use steroids for muscle building. 


The Dangers of Counterfeit Steroids 
One of the primary effects of our government's crackdown on legitimate anabolic steroids has been the expansion of a huge black market of counterfeit products. While estimates vary widely, many authorities assert that the majority of anabolics available on the black market are fakes. These counterfeits are manufactured under unsupervised and potentially unsanitary conditions, and may contain no real androgens at all (see, Di Pasquale, 1995). They may also be contaminated with bacteria or other dangerous substances. Noted steroid expert Dr. Robert Price: "My colleagues at Mount Sinai Hospital in New York tell me they are treating many more athletes for side effects of counterfeit and bogus steroids than they did when reliable pharmacy-purchased steroids were available" (Allen, 1998, p. 224). 

If the health dangers of real anabolic steroids have been overstated, the dangers of counterfeit anabolics may be understated. The problem is particularly serious because of how difficult it is to distinguish a real product from a counterfeit knock-off. As an example of these very subtle differences, compare legitimate versus counterfeit Anapolon 50 tablets by Syntex (Grunding & Bachmann, 1996, pp. 349-351, photographs at 357-358, 361). 


Conclusion 
It can be concluded that "[a]s used by most athletes, the side effects of anabolic steroid use appear to be minimal" (Di Pasquale, 1990, p. 5). Despite over forty years of use by athletes, many of whom are now well into middle-age, we have yet to hear reports of an epidemic of steroid-related deaths. A review of the medical literature does not support the depiction of a serious health crisis related to anabolic steroids. Of course, it would be untrue to say that anabolic steroids, especially black market products, are safe for unsupervised, unmonitored self-administration. On the other hand, it would be equally untrue to say that anabolics are "deadly drugs" deserving of the imposition of harsh criminal penalties for personal use by adults. Accordingly, there is a serious question as to whether Congress may have grossly overreacted in addressing the non-medical use of anabolic steroids by athletes. For further discussion of this issue, and why dispensing steroids should be put back in the hands of trained physicians instead of the black market's dubious "experts," see the section entitled Do Our Anabolic Steroid Laws Work?.